Guillaume Bonniaud

The conundrum of hodgkin lymphoma nodes: To be or not to be included in the involved node radiation fields. The EORTC-GELA lymphoma group guidelines

PURPOSE To develop easily applicable guidelines for the determination of initially involved lymph nodes to be included in the radiation fields. PATIENTS AND METHODS Patients with supra-diaphragmatic Hodgkin lymphoma. All the imaging procedures were carried out with patients in the treatment position. The prechemotherapy PET/CT was coregistered with the postchemotherapy CT simulation for planning purposes. Initially involved lymph nodes were determined on fused prechemotherapy CT and FDG-PET imaging data. The initial assessment was verified with the postchemotherapy CT scan. RESULTS The classic guidelines for determining the involvement of lymph nodes were not easily applicable and did not seem to reflect the exact extent of Hodgkin lymphoma. Three simple steps were used to pinpoint involved lymph nodes. First, FDG-PET scans were meticulously analysed to detect lymph nodes that were overlooked on CT imaging. Second, any morphological and/or functional asymmetry was sought on CT and FDG-PET scans. Third, a decrease in size or the disappearance of initially visible lymph nodes on the prechemotherapy CT scan as compared to the postchemotherapy CT scan was considered as surrogate proof of initial involvement. CONCLUSIONS All the radiological procedures should be performed on patients in the treatment position for proper coregistration. It is highly advisable that all CT and/or CT/PET scans be performed with IV contrast. Using the above-mentioned three simple guidelines, initially involved lymph nodes can be detected with very satisfactory accuracy. It is also emphasized that the classic guidelines (2, 3, 4) can always be used when deemed necessary.

/sup 18/F-FDG PET images segmentation using morphological watershed: a phantom study

Segmentation of 18F-FDG PET images could be helpful for delineation of tumor volume in radiotherapy and patient follow-up. The most commonly implemented method on clinical workstations is maximum intensity thresholding, which is inappropriate for heterogeneous uptakes. Our aim was to develop and evaluate a more sophisticated segmentation method, based on the morphological watershed. We developed a segmentation method taking into account PET images characteristics. We evaluated it first on phantom images, using an integrated PET/CT unit and taking CT images as reference images. To simulate tumors in a background activity, we used 6 homogeneous spheres of various volumes in a cylindrical phantom and 3 heterogeneous cylinders in an anthropomorphic phantom. The quality of segmentation was evaluated in terms of volume, shape and position. We compared the results with a maximum intensity threshold segmentation method fitting the volume, taken as reference segmentation. A quantitation analysis completed the phantom study. For both phantom acquisitions, the segmentation obtained with the watershed based algorithm gave satisfying results with the index integrating volume, shape and position. Results considering this index were not significantly different from the reference segmentation (p > 0.5). Errors of volume recovery reached 18% for watershed segmentation. The quantitation analysis on phantoms highlighted partial volume effect, with an error of activity concentration measurement on segmented images ranging between 42% and 51%. Performances of the watershed method evaluated in this study were comparable with an optimized segmentation on phantom images. The quantitation recovery of PET regions with this method was similar with to other segmentation methods.

Individual radiation therapy patient whole-body phantoms for peripheral dose evaluations: method and specific software

This study presents a method aimed at creating radiotherapy (RT) patient-adjustable whole-body phantoms to permit retrospective and prospective peripheral dose evaluations for enhanced patient radioprotection. Our strategy involves virtual whole-body patient models (WBPM) in different RT treatment positions for both genders and for different age groups. It includes a software tool designed to match the anatomy of the phantoms with the anatomy of the actual patients, based on the quality of patient data available. The procedure for adjusting a WBPM to patient morphology includes typical dimensions available in basic auxological tables for the French population. Adjustment is semi-automatic. Because of the complexity of the human anatomy, skilled personnel are required to validate changes made in the phantom anatomy. This research is part of a global project aimed at proposing appropriate methods and software tools capable of reconstituting the anatomy and dose evaluations in the entire body of RT patients in an adapted treatment planning system (TPS). The graphic user interface is that of a TPS adapted to obtain a comfortable working process. Such WBPM have been used to supplement patient therapy planning images, usually restricted to regions involved in treatment. Here we report, as an example, the case of a patient treated for prostate cancer whose therapy planning images were complemented by an anatomy model. Although present results are preliminary and our research is ongoing, they appear encouraging, since such patient-adjusted phantoms are crucial in the optimization of radiation protection of patients and for follow-up studies.

A phantom study of the accuracy of CT, MR and PET image registrations with a block matching-based algorithm

PURPOSE The aim of the present study was to quantitatively assess the performance of a block matching-based automatic registration algorithm integrated within the commercial treatment planning system designated ISOgray from Dosisoft. The accuracy of the process was evaluated by a phantom study on computed tomography (CT), magnetic resonance (MR) and positron emission tomography (PET) images. MATERIALS AND METHODS Two phantoms were used to carry out this study: the cylindrical Jaszczak phantom and the anthropomorphic Liqui-Phil Head Phantom (the Phantom Laboratory), containing fillable spheres. External fiducial markers were used to quantify the accuracy of 41 CT/CT, MR/CT and PET/CT automatic registrations with images of the rotated and tilted phantoms. RESULTS The study first showed that a cylindrical phantom was not adapted for the evaluation of the performance of a block matching-based registration software. Secondly, the Liqui-Phil Head Phantom study showed that the algorithm was able to perform automatic registrations of CT/CT and MR/CT images with differences of up to 40 degrees in phantom rotation and of up to 20-30 degrees for PET/CT with accuracy below the image voxel size. CONCLUSION The study showed that the block matching-based automatic registration software under investigation was robust, reliable and yielded very satisfactory results. This phantom-based test can be integrated into a periodical quality assurance process and used for any commissioning of image registration software for radiation therapy.

Dedicated treatment planning system for the evaluation of the doses delivered to the whole patient body during radiotherapy

Describe the principles and report the preliminary results on dose distributions obtained with a new generation of treatment planning system (TPS) designed to provide, in addition to the dose distributions within the target-volumes, the magnitude of the doses to distant healthy tissues in the course of common radiotherapy procedures. The system is made of (1) a library of adjustable whole-body patient models in radiotherapy treatment position, allowing different patient anatomies to be simulated, (2) a global-beam model allowing the dosimetric data of the irradiation beams to be extended to the whole body and (3) a TPS modified to handle the two first modules in order to produce the dose distributions within the target-volumes and in any organ at distance. Our preliminary results indicate that in an adult male patient treated by radiotherapy for Hodgkin disease using two opposed 6 MV photon beams, the mean doses to distant organs are: 0.9 % of the target volume dose for the pituitary gland, 0.40% to 3.4% for the kidneys, 0.43% for the prostate, and at larger distance, 0.07% and 0.02 % at the level of the knees and the feet respectively. Although the development of our system is still in progress, the preliminary results are encouraging. This systematic evaluation of the low doses delivered at distance of the targetvolumes is a basic requirement for prospective studies of longterm risks of modern radiotherapy procedures.